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Borderline Personality Disorder
DSM-II In DSM-II, this disorder is called Schizophrenia, latent type For more information, see Schizophrenia This category is for patients having clear symptoms of schizophrenia but no history of a psychotic schizophrenic episode. Disorders sometimes designated as incipient, pre-psychotic, pseudoneurotic, pseudo-psychopathic, or borderline schizophrenia are categorized here. DSM-III Diagnostic Criteria The following are characteristic of the individual's current and long-term functioning, are not limited to episodes of illness, and cause either significant impairment in social or occupational functioning or subjective distress. A'''. At least five of the following are required: # impulsivity or unpredictability in at least two areas that are potentially self-damaging, e.g., spending, sex, gambling, substance use, shoplifting, overeating, physical self-damaging acts # a pattern of unstable and intense interpersonal relationships, e.g., marked shifts of attitude, idealization, devaluation, manipulation (consistently using others for one's own ends) # inappropriate, intense anger or lack of control of anger, e.g., frequent displays of temper, constant anger # identity disturbance manifested by uncertainty about several issues relating to identity, such as self-image, gender identity, long-term goals or career choice, friendship patterns, values, and loyalties, e.g., "Who am I?", "I feel like I am my sister when I am good" # affective instability: marked shifts from normal mood to depression, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days, with a return to normal mood # intolerance of being along, e.g., frantic efforts to avoid being alone, depressed when alone # physical self-damaging acts, e.g., suicidal gestures, self-mutilation, recurrent accidents of physical fights # chronic feelings of emptiness or boredom '''B. If under 18, does not meet the criteria for Identity Disorder. Differential Diagnosis Identity Disorder In Identity Disorder there is a similar clinical picture and this diagnosis preempts the diagnosis of Borderline Personality Disorder if the individual is under 18. Cyclothymic Disorder In Cyclothymic Disorder there is also affective instability, but in Borderline Personality Disorder there are no hypomanic periods. However, in some cases, both disorders may coexist. DSM-IV Diagnostic Criteria A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: # frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. # a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation # identity disturbance: markedly and persistently unstable self-image or sense of self # impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. # recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior # affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) # chronic feelings of emptiness # inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) # transient, stress-related paranoid ideation or severe dissociative symptoms Differential Diagnosis Mood Disorders Borderline Personality Disorder often co-occurs with Mood Disorders, and when criteria for both are met, both may be diagnosed. Because the cross-sectional presentation of Borderline Personality Disorder can be mimicked by an episode of Mood Disorder, the clinician should avoid giving an additional diagnosis of Borderline Personality Disorder based only on cross-sectional presentation without having documented that the pattern of behavior has an early onset and a long-standing course. Other Personality Disorders Other Personality Disorders may be confused with Borderline Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Borderline Personality Disorder, all can be diagnosed. Histrionic Personality Disorder Although Histrionic Personality Disorder can also be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, Borderline Personality Disorder is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness. Schizotypal Personality Disorder Paranoid ideas or illusional may be present in both Borderline Personality Disorder and Schizotypal Personality Disorder, but these symptoms are more transient, interpersonally reactive, and responsive to external structuring in Borderline Personality Disorder Paranoid and Narcissistic Personality Disorders Although Paranoid Personality Disorder and Narcissistic Personality Disorder may also be characterized by an angry reaction to minor stimuli, the relative stability of self-image as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns distinguish these disorders from Borderline Personality Disorder. Antisocial Personality Disorder Although Antisocial Personality Disorder and Borderline Personality Disorder are both characterized by manipulative behavior, individuals with Antisocial Personality Disorder are manipulative to gain profit, power, or some other material gratification, whereas the goal in Borderline Personality Disorder is directed more towards gaining the concern of caretakers. Dependent Personality Disorder Both Dependent Personality Disorder and Borderline Personality Disorder are characterized by fear of abandonment; however, the individual with Borderline Personality Disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas the individual with Dependent Personality Disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline Personality Disorder can further be distinguished from Dependent Personality Disorder by the typical pattern of unstable and intense relationships. Personality Change Due to a General Medical Condition and symptoms related to substance use Borderline Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified). Identity Problem Borderline Personality Disorder should be distinguished from Identity Problem, which is reserved for identity concerns related to a developmental phase (e.g., adolescence) and does not qualify as a mental disorder. DSM-5 Diagnostic Criteria A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: # Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) # A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. # Identity disturbance: markedly and persistently unstable self-image or sense of self. # Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) # Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. # Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). # Chronic feelings of emptiness. # Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). # Transient, stress-related paranoid ideation or severe dissociative symptoms. Alternative Model Proposed Diagnostic Criteria A'''. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas: # ''Identity'': Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress. # ''Self-direction'': Instability in goals, aspirations, values, or career plans. # ''Empathy'': Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities. # ''Intimacy'': Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imaged abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between overinvolvement and withdrawal. '''B. Four or more of the following seven pathological personality traits, at least one of which must be (5) Impulsivity, (6) Risk taking, or (7) Hostility: # Emotional lability (an aspect of Negative Affectivity): Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances. # Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control. # Separation insecurity (an aspect of Negative Affectivity): Fears of rejection by - and/or separation from - significant others, associated with fears of excessive dependency and complete loss of autonomy. # Depressivity (an aspect of Negative Affectivity): Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feelings of inferior self-worth; thoughts of suicide and suicidal behavior. # Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress. # Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one's limitations and denial of the reality of personal danger. # Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults. C'''. The impairments in personality functioning and the individual's personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations. '''D. The impairments in personality functioning and the individual's personality trait expression are relatively stable across time, with onsets that can be traced back to at least adolescence or early adulthood. E'''. The impairments in personality functioning and the individual's personality trait expression are not better explained by another mental disorder. '''F. The impairments in personality functioning and the individual's personality trait expression are not solely attributable to the physiological effects of a substance or another medical condition (e.g., severe head trauma). G'''. The impairments in personality functioning and the individual's personality trait expression are not better understood as normal for an individual's developmental stage or sociocultural environment. '''Specifiers Trait and level of personality functioning specifiers may be used to record additional personality features that may be present in borderline personality disorder but are not required for the diagnosis. For example, traits of Psychoticism (e.g., cognitive and perceptual dysregulation) are not diagnostic criteria for borderline personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of borderline personality disorder (Criterion A), the level of personality functioning can also be specified. Differential Diagnosis Depressive and bipolar disorders Borderline personality disorder often co-occurs with depressive or bipolar disorders, and when criteria for both are met, both may be diagnosed. Because the cross-sectional presentation of borderline personality disorder can be mimicked by an episode of depressive or bipolar disorder, the clinician should avoid giving an additional diagnosis of borderline personality disorder based only on cross-sectional presentation without having documented that the pattern of behavior had an early onset and a long-standing course. Other personality disorders Other personality disorders may be confused with borderline personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to borderline personality disorder, all can be diagnosed. Histrionic personality disorder Although histrionic personality disorder can also be characterized by attention seeking manipulative behavior, and rapidly shifting emotions, borderline personality disorder is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness. Schizotypal personality disorder Paranoid ideas or illusions may be present in both borderline personality disorder and schizotypal personality disorder, but these symptoms are more transient, interpersonally reactive, and responsive to external structuring in borderline personality disorder. Paranoid and narcissistic personality disorder Although paranoid personality disorder and narcissistic personality disorder may also be characterized by an angry reaction to minor stimuli, the relative stability of self-image, as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns, distinguishes these disorders from borderline personality disorder. Antisocial personality disorder Although antisocial personality disorder and borderline personality disorder are both characterized by manipulative behavior, individuals with antisocial personality disorder are manipulative to gain profit, power, or some other material gratification, whereas the goal in borderline personality disorder is directed more toward gaining the concern of caretakers. Dependent personality disorder Both dependent personality disorder and borderline personality disorder are characterized by fear of abandonment; however, the individual with borderline personality disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas the individual with dependent personality disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline personality disorder can further be distinguished from dependent personality disorder by the typical pattern of unstable and intense relationships. Personality change due to another medical condition Borderline personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system. Substance use disorders Borderline personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use. Identity problems Borderline personality disorder should be distinguished from an identity problem, which is reserved for identity concerns related to a developmental phase (e.g., adolescence) and does not qualify as a mental disorder.